Confirm Your Registration for the 2012 MFDW

Complete the following form and click on SUBMIT to confirm your registration.

The deadline for confirming your registration is Friday, February 3, 2012.

This registration form is for use only by applicants accepted to the workshop. If you have not been notified of your acceptance, do not complete this form. Please contact Gail Spatt (spatt@gatech.edu, 404.385.8774) with any questions.

Contact Information

First Name:

Last Name:

Name for badge (first or nickname):

Email Address:

(Please Note: Your email address is what we use to track your application and participation in the workshop. Be sure to use the same email address in all forms relating to your workshop participation. This email will also be our primary means of communication with you. Please double-check that you have typed it correctly.)Cell Phone Number (this information is only used to contact you if there are issues that arise during your transit to or from the workshop):

If there is anyone you would like us to contact in the unlikely event of an emergency during the workshop, please enter their name and contact information here:

Travel Information

Atlanta-based participants are not eligible for flight or hotel. Please check the box below if you will need a parking voucher at the Global Learning Center.

I will need a parking voucher.

All other participants: your inbound flight must arrive no later than 4 pm on Thursday, March 15 and your outbound flight must depart no earlier than 5 pm on Sunday, March 18. Someone from our travel agency, Travel Inc., will be contacting you to assist with booking your flights. To expedite the process, we will provide them with the information below after you fill out this form.

Your name as it appears on your government-issued ID (don't forget middle name or initial if applicable):

Date of birth:

Seat preference:

Phone number at which Travel Inc. should contact you:

Email address at which Travel Inc. should contact you:

You can book your hotel room immediately but must do so absolutely no later than February 10, 2012. Please note that as you go through the process you will see the rates but will not be asked to pay anything. It is extremely important that when you fill in your information, you type the letters "MFDW" into the Comments/Special Requests box. Here are the instructions from the hotel:

Use this link to book your room(opens in a new window). (Guests can also access the Minority Faculty Development Workshop reservations link by logging on to our website (www.gatechhotel.com), clicking on the button "Group Booking" and entering the group password – "mfdw0312") in lower-case letters only.

Both non-smoking King and Two Queen bedding accommodations have been blocked for this group. Please note that all guestrooms are non-smoking. For any other requests or inquiries, please enter this information within the appropriate request boxes during the reservations process or call the hotel directly by calling (800) 706-2899 or (404) 838-2100.

Do you have a disability, food allergy, or preference that requires accommodation at the workshop? If so please describe:

Do you anticipate difficulty walking moderate distances?

Yes No

Workshop Product Release
In confirming my registration for this workshop, I agree that any audio recording or images (still or video) made of me during the workshop may be used on the project website, in printed project publications, and in materials developed by the project. I further agree that my contributions to creative works that emerge from workshop activities (e.g., discussions on the email list, contributions to the web page, summaries of group discussion, etc.) may be used by the workshop series, PIs, and conveners for development of future workshop materials, for scholarly reports, and for promotion of the workshop series. Attribution for original contributions will be made whenever possible.

I understand that I must attend the full workshop, which begins at 6:00 pm on Thursday, March 15 and concludes at 2:30 pm on Sunday, March 18. If I do not attend the full workshop, I am in violation of the funding terms and could be responsible for reimbursement costs.
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